Individual
OTTO LIEBMANN
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
593 EDDY ST, CLAVERICK 2, PROVIDENCE, RI 02903-4923
(401) 519-1604
(401) 272-0538
Mailing address
125 WHIPPLE ST STE 3, PROVIDENCE, RI 02908-3258
(401) 519-0337
Taxonomy
Speciality
Code
Description
License number
State
207P00000X
Emergency Medicine Physician
Primary
MD12526
RI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
007059786
RI MEDICARE
RI
01
—
1/27/2009
TUFTS HEALTH PLAN
MA
01
—
1023039146
NPI
RI
01
—
12/13/2007
NHPRI
RI
05
—
2145464
—
MA
05
—
2145464
—
RI
01
—
414642
BCBSRI
RI
01
—
939025129
MEDICARE GROUP NUMBER
RI
01
—
P00671205
RAILROAD MEDICARE
—
Enumeration date
07/22/2006
Last updated
08/31/2020
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